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S P E C I A L C O M M U N I C A T I O N
Neonatal Physical Therapy. Part I:Clinical Competencies andNeonatal Intensive Care UnitClinical Training ModelsJane K. Sweeney, PT, PhD, PCS, FAPTA, Carolyn B. Heriza, PT, EdD, FAPTA, and Yvette Blanchard, PT, ScD
Doctoral Programs in Pediatric Science (J.K.S., C.B.H.), Rocky Mountain University of Health Professions, Provo, Utah; PediatricRehab Northwest LLC (J.K.S.), Gig Harbor, Washington; and Physical Therapy Program (Y.B.), University of Hartford,Hartford, Connecticut
Purpose: To describe clinical training models, delineate clinical competencies, and outline a clinical decision-making algorithm for neonatal physical therapy. Key Points: In these updated practice guidelines, advanced clinicaltraining models, including precepted practicum and residency or fellowship training, are presented to guidepractitioners in organizing mentored, competency-based preparation for neonatal care. Clinical competencies inneonatal physical therapy are outlined with advanced clinical proficiencies and knowledge areas specific to eachrole. An algorithm for decision making on examination, evaluation, intervention, and re-examination processesprovides a framework for clinical reasoning. Because of advanced-level competency requirements and the contin-uous examination, evaluation, and modification of procedures during each patient contact, the intensive care unitis a restricted practice area for physical therapist assistants, physical therapist generalists, and physical therapystudents. Conclusions/Practice Implications: Accountable, ethical physical therapy for neonates requires advanced,competency-based training with a preceptor in the pediatric subspecialty of neonatology. (Pediatr Phys Ther2009;21:296–307) Key words: clinical competence, reference standards/clinical, high-risk infant, neonatal intensivecare units, neonatology, physical therapy, clinical practice guidelines, preterm infant, training models
INTRODUCTION
Neonatal physical therapy is an advanced practice area inpediatric physical therapy that has evolved from the early1970s when regional neonatal intensive care units (NICUs)were established and neonatal mechanical ventilation becameavailable to increase survival in infants born preterm in ter-tiary units. In today’s NICUs and intermediate care units, neo-natal physical therapists (PTs) require advanced training andcompetencies to safely and effectively meet the neurodevel-
opmental and musculoskeletal needs of infants who havebeen physiologically unstable as well as the educational andemotional needs of their parents, who are highly stressed. Theneonatal PT must acquire the comprehensive knowledge andclinical competencies in neonatal care to participate as equalpartners with the team of neonatal nurses and neonatologistswho have completed subspecialty neonatal training and cer-tification in their respective disciplines.
Clinical practice guidelines for pediatric PTs in theNICU are presented in two sections: part 1: specialized train-ing models, clinical competencies, and decision-making algo-rithm and part II: NICU practice frameworks and evidence-based practice considerations. This article focuses on part Iwith part II to follow in the next issue of Pediatric PhysicalTherapy.
CLINICAL TRAINING
Neonatal practice is a highly specialized area withinpediatric physical therapy in which vulnerable infants withcomplex medical, physiological, and behavioral conditionsmay inadvertently be harmed through examination and
0898-5669/109/2104-0296Pediatric Physical TherapyCopyright © 2009 Section on Pediatrics of the American PhysicalTherapy Association.
Address Correspondence to: Jane K. Sweeney, PT, PhD, PCS, FAPTA,8814 30th Street, Ct NW, Gig Harbor, WA 98335. E-mail:[email protected] Support: Supported in part by the Section on Pediatrics, APTA, forwhich the authors served as members of the NICU Task Force.
DOI: 10.1097/PEP.0b013e3181bf75ee
296 Sweeney et al Pediatric Physical Therapy
intervention procedures. The NICU is not an appropri-ate setting for PT assistants, PT generalists, and PT stu-dents. Pediatric PTs need expanded training in manyareas including family systems, NICU environment, col-laborative team work in a critical care unit, infant devel-opment, brain development, physiological evaluation andmonitoring, and infant neurobehavioral functioning. Evenroutine caregiving procedures may pose risks to fragileneonates with physiological and metabolic instabilityand incompletely developed musculoskeletal, neuro-muscular, cardiovascular/pulmonary, and integumen-tary systems. Continuous examination and evaluationare required during each contact to determine whetherthe infant is beginning to move outside the limits ofphysiological, motor, or behavioral state stability duringhandling or feeding. Because of the complexity involvedin communication and teaching for stressed, grievingfamilies, advanced training and mentoring are indicatedin grief management, crisis intervention, family systems,and adult learning approaches.
Several clinical training models may be consideredby pediatric PTs preparing for neonatal practice: pre-cepted practicum, neonatology fellowship, or neonataltraining as a part of a pediatric residency. The length ofclinical training in neonatal care may vary from 2 to 6months depending on the following variables:
• Practitioner’s previous experience in pediatrics, espe-cially early intervention practice, hospital-based in-fant and pediatric care, and exposure to training inbehavioral observations of fragile neonates. Practitio-ners with previous experience and training with frag-ile infants will likely require a shorter practicum du-ration to become independent in competency-basedtraining requirements;
• Individualized, precepted practicum based on thelevel of acuity and regional and local variables suchas cultural diversity and healthcare reimbursementto match the demographics of the future NICUpractice setting of the trainee; and
• Completed American Physical Therapy Associa-tion (APTA)-accredited neonatology fellowship orpediatric residency program that includes a neona-tology rotation.
Resources on neonatal topics to support clinical train-ing are available on the Neonatology Special Interest Grouplink on the Section on Pediatrics, APTA Web site: www.pediatricapta.org. Parent education brochures, NICU-relatedvideos/CDs, and continuing education courses are outlined.
Precepted Practicum
Sequenced, gradual entry to neonatal care is advisedwith clinical experience starting with infants born full-termand older, medically fragile, hospitalized children requiringrespiratory equipment and cardiorespiratory monitor instru-mentation. These children, while medically fragile, are usu-ally more stable than infants born preterm and on ventilatorequipment in the NICU. As such, they are less vulnerable to
inadvertent overstimulation from professionals in a subspe-cialty training process. Gradual entry to the NICU after expe-rience in a pediatric ICU, pediatric ward, newborn nursery,and intermediate care nursery is strongly advised before at-tempting to examine or intervene with infants and parents inthe NICU. Observations of nursing care and respiratory ther-apy for fragile infants with complex medical conditions areadditional valuable components in mentored training.
Exposure to the developmental trajectory and neuromo-tor patterns in outpatient follow-up for NICU graduates is acritical learning experience for all neonatal therapists andshould be included in a precepted practicum. This valuableexperience helps develop a perspective on various neonatalneuromotor findings (ie, asymmetry, tone abnormalities, jit-tery movement), which may turn out to be transient. Theclinical follow-up also provides valuable opportunities to seethe parents outside the NICU environment, learn abouttheir ongoing challenges and successes in caregiving,and adapt the neonatal therapy program to their currentpriorities. Observation and participation with pediatricPTs working with NICU graduates in home-based andcommunity-based early intervention programs are ad-vised to enhance NICU discharge planning skills andliaison with community resources.
Precepted practicum opportunities may be accessedthrough selected medical centers. An alternative method isuniversity-based, specialized training modules for experi-enced pediatric therapists through directed clinical studiesas a part of advanced doctoral study.
Residency or Fellowship Training
Now that the opportunity for residency training inpediatrics is offered in the United States, PTs may accessprecepted NICU training through a pediatric residencyprogram. Pediatric residencies accredited by the APTAhave a minimum length of 10 months, a part of whichmay be conducted in an NICU setting depending on thepractice scope of the residency program. Shortly, APTA-accredited neonatology fellowship programs will beavailable and will offer comprehensive preparation forappropriate, accountable, evidence-based, and ethicalpractice in neonatal physical therapy. Regardless of themodel of training selected for neonatal practice prepara-tion, clinical competencies specific to newborn infantsand families should guide the training and provide anevaluation structure for trainees.
CLINICAL COMPETENCIES
The clinical roles and proficiencies for neonatal PTs, de-veloped by task forces from the Section on Pediatrics, APTA,were first documented in 19891 and expanded in 1999.2 Thecompetencies for neonatal physical therapy practice in thesecurrent updated practice guidelines are delineated by roles,clinical proficiencies, and knowledge areas. The roles ofthe neonatal PT such as screening, examination/evalua-tion, intervention,consultation, scientific inquiry, clini-cal education/professional development, and adminis-tration are organized in Tables 1 to 7. The neonatal
Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 297
TABL
E1
Scre
enin
g
Rol
esC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Scre
enN
ICU
infa
nt
popu
lati
onto
dete
rmin
eth
en
eed
for
phys
ical
ther
apy
serv
ices
base
don
esta
blis
hed
refe
rral
ordi
agn
osti
ccr
iter
ia.
●Id
enti
fyan
din
terp
ret
peri
nat
alan
dm
edic
alh
isto
ryan
dcu
rren
tin
fan
tst
atu
sby
char
tre
view
and
inte
rvie
ws
ofn
eon
atal
care
give
rsto
dete
rmin
en
euro
deve
lopm
enta
lris
k.●
Iden
tify
and
inte
rpre
tfa
mil
yin
form
atio
nre
late
dto
infa
nt
care
givi
ng
byin
terv
iew
sof
fam
ily
mem
bers
toan
alyz
epo
ten
tial
envi
ron
men
talr
isk.
●O
bser
vein
fan
t-pa
ren
t(o
rde
sign
ated
care
give
r)ca
regi
vin
gpa
tter
ns,
reco
gniz
ead
apti
vean
dm
alad
apti
vebe
hav
iors
,an
dde
term
ine
nee
dfo
rad
diti
onal
fam
ily
supp
ort
serv
ices
.●
Rec
ogn
ize
con
sist
ent
sign
sof
neu
robe
hav
iora
lorg
aniz
atio
nor
diso
rgan
izat
ion
inth
eph
ysio
logi
cal,
mot
or,a
nd
stat
esy
stem
sth
rou
ghre
peat
edob
serv
atio
ns
ofin
fan
tca
regi
vin
gan
dso
cial
inte
ract
ion
.●
Iden
tify
infa
nts
for
refe
rral
toP
Tth
rou
ghpa
rtic
ipat
ion
inN
ICU
med
ical
orde
velo
pmen
talr
oun
ds.
●N
ICU
med
ical
term
inol
ogy
and
abbr
evia
tion
s.●
Epi
dem
iolo
gyan
dpa
thop
hys
iolo
gyof
pren
atal
,per
inat
al,a
nd
post
nat
aldi
agn
oses
onsu
bseq
uen
tn
euro
deve
lopm
ent.
●F
amil
ysy
stem
san
din
terv
iew
proc
esse
s.●
Infa
nt-
pare
nt
inte
ract
ion
patt
ern
san
dat
tach
men
tpr
oces
sam
ong
fam
ilie
sof
infa
nts
deve
lopi
ng
typi
call
yan
dat
hig
hri
sk.
●T
ypic
alan
dat
ypic
alpr
enat
alan
dpo
stn
atal
deve
lopm
ent.
●E
tiol
ogy
and
path
oph
ysio
logy
ofco
mm
onm
edic
alco
ndi
tion
sen
cou
nte
red
inth
eN
ICU
popu
lati
on.
●T
ypic
alde
velo
pmen
talc
ompe
ten
cies
ofin
fan
tsat
vari
ous
gest
atio
nal
ages
.●
Indi
cati
ons
for
and
effe
cts
ofge
ner
alm
edic
alpr
oced
ure
sin
neo
nat
alca
re.
●E
ffec
tsof
the
NIC
Uph
ysic
alen
viro
nm
ent
(lig
ht,
sou
nd,
tast
e,sm
ell)
onth
ein
fan
t.
Dev
elop
and
impl
emen
ta
risk
man
agem
ent
plan
for
each
infa
nt
topr
even
tn
euro
beh
avio
ral
diso
rgan
izat
ion
(ph
ysio
logi
cal,
mot
or,a
nd
stat
esy
stem
s)an
dse
con
dary
com
plic
atio
ns
inm
usc
ulo
skel
etal
,n
euro
mu
scu
lar,
and
inte
gum
enta
rysy
stem
san
dto
max
imiz
en
euro
deve
lopm
enta
lfu
nct
ion
.
●R
ecog
niz
eph
ysio
logi
cals
tatu
sin
anin
fan
tby
inte
rpre
tin
gau
ton
omic
resp
onse
sfr
omth
ein
fan
t(e
g,h
eart
rate
,res
pira
tory
rate
and
brea
thin
gpa
tter
n,o
xyge
nsa
tura
tion
,col
or,b
lood
pres
sure
,an
dte
mpe
ratu
re)
and
data
from
mon
itor
ing
equ
ipm
ent
duri
ng
phys
ical
ther
apy
exam
inat
ion
and
inte
rven
tion
,rou
tin
eca
re,f
eedi
ng,
and
soci
alin
tera
ctio
n.
●Id
enti
fyan
din
terp
ret
infa
nt
atte
mpt
san
dsu
cces
ses
atse
lf-r
egu
lati
onre
flec
ted
thro
ugh
beh
avio
ralc
ues
inph
ysio
logi
cals
tatu
s,m
ovem
ent
and
post
ure
,sta
te,a
tten
tion
,an
dso
cial
inte
ract
ion
.●
Con
duct
obse
rvat
ion
ofth
ein
fan
tpr
ior,
duri
ng,
and
afte
rh
andl
ing
tode
term
ine
neu
robe
hav
iora
lrea
din
ess,
cost
,an
dre
cove
ryre
late
dto
phys
ical
ther
apy
exam
inat
ion
and
inte
rven
tion
.●
Rec
ogn
ize
and
prev
ent
pote
nti
alan
dia
trog
enic
neu
rom
usc
ulo
skel
etal
,in
tegu
men
tary
,an
din
fect
ion
com
plic
atio
ns
and
impl
emen
tap
prop
riat
epo
siti
onin
gst
rate
gies
topr
even
tor
amel
iora
teth
ese
impa
irm
ents
.●
Loc
ate
alll
eads
,lin
es,a
nd
resp
irat
ory
tubi
ng
from
the
infa
nt
toth
em
edic
aleq
uip
men
tan
dex
plai
nth
ege
ner
alfu
nct
ion
ofea
chat
tach
edeq
uip
men
tu
nit
.●
Dem
onst
rate
appr
opri
ate
han
dlin
gof
infa
nts
wit
hin
crea
sin
gly
com
plex
med
ical
nee
dson
phys
iolo
gica
lmon
itor
s,re
spir
ator
yeq
uip
men
t,in
fusi
onor
pare
nte
ralf
eedi
ng
lin
es,a
nd
oth
erm
edic
alsu
ppor
tde
vice
s.●
An
alyz
ean
dm
odif
yth
eph
ysic
alan
dso
cial
envi
ron
men
tu
sin
gen
viro
nm
enta
lsu
ppor
tm
easu
res
(eg,
posi
tion
ing
aids
,lig
ht,
and
sou
nd
con
trol
mea
sure
s)an
din
divi
dual
ized
care
givi
ng
proc
edu
res
toop
tim
ize
neu
rode
velo
pmen
tof
alli
nfa
nts
and,
inpa
rtic
ula
r,n
euro
beh
avio
ral
resp
onse
sof
infa
nts
ath
igh
risk
toph
ysic
alth
erap
yex
amin
atio
nan
din
terv
enti
on.
●A
ccep
tabl
era
nge
ofph
ysio
logi
calp
aram
eter
sba
sed
onac
uit
yle
vels
and
ages
ofn
eon
ates
.●
Ran
geof
neu
rom
usc
ula
ran
dm
usc
ulo
skel
etal
para
met
ers
base
don
ages
ofn
eon
ates
.●
Neu
robe
hav
iora
lcu
essi
gnal
ing
hom
eost
asis
and
self
-cal
min
g(e
nga
gem
ent)
,as
wel
las
cues
indi
cati
ng
stre
ssan
dov
erst
imu
lati
on(d
isen
gage
men
t).
●G
ener
alfu
nct
ion
ofal
lmed
ical
equ
ipm
ent,
lin
es,a
nd
lead
sat
tach
edto
the
infa
nts
.●
Man
agem
ent
prec
auti
ons
for
neo
nat
esw
ith
post
oper
ativ
em
edic
alpr
oced
ure
s,ca
rdia
can
dpu
lmon
ary
diso
rder
s,an
dse
ptic
con
diti
ons.
●D
evel
opm
ent
ofn
euro
mu
scu
lar,
mu
scu
losk
elet
al,i
nte
gum
enta
ry,
sen
sory
,car
diov
ascu
lar/
pulm
onar
yan
dot
her
phys
iolo
gica
lsys
tem
sin
the
fetu
s(e
g,ga
stro
inte
stin
al;m
etab
olic
).●
Epi
dem
iolo
gy,e
mbr
yolo
gy,a
nd
asso
ciat
edn
euro
deve
lopm
enta
lris
kof
pote
nti
alfe
talm
alfo
rmat
ion
s,de
form
atio
ns,
and
expo
sure
con
sequ
ence
sfr
omm
ater
nal
infe
ctio
ns,
subs
tan
ceab
use
,an
din
adeq
uat
en
utr
itio
n.
●E
colo
gyof
the
NIC
U(p
hys
ical
and
soci
ocu
ltu
rale
nvi
ron
men
t).
●In
tera
ctio
nbe
twee
nen
viro
nm
enta
lfac
tors
and
deve
lopm
ent
inN
ICU
and
hom
ese
ttin
gs.
NIC
Uin
dica
tes
neo
nat
alin
ten
sive
care
un
it.
298 Sweeney et al Pediatric Physical Therapy
TABL
E2
Exa
min
atio
nan
dE
valu
atio
n
Rol
eC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Exa
min
ein
fan
tan
din
terp
ret
fin
din
gs.
●Se
lect
and
con
duct
clin
ical
exam
inat
ion
san
dev
alu
atio
ns
appr
opri
ate
for
infa
nt’s
gest
atio
nal
age
and
phys
iolo
gica
lsta
bili
ty.
●A
dmin
iste
rst
anda
rdiz
edte
sts
and
mea
sure
sw
ith
mod
ific
atio
n(o
rst
oppi
ng)
toac
com
mod
ate
the
infa
nt’s
neu
robe
hav
iora
lan
dph
ysio
logi
calc
han
ges,
resp
irat
ory
and
infu
sion
equ
ipm
ent,
nu
rsin
g/ca
regi
vin
gsc
hed
ule
,an
dfa
mil
yco
nce
rns
and
prio
riti
es.
●E
valu
ate
neu
robe
hav
iora
lvu
lner
abil
itie
san
dle
velo
ffu
nct
ion
and
reco
mm
end
deve
lopm
enta
lly
appr
opri
ate
plan
ofca
re.
●M
ovem
ent
char
acte
rist
ics
ofin
fan
tsbo
rnat
term
orpr
eter
mge
stat
ion
,in
clu
din
gra
nge
ofm
otio
n,d
evel
opm
enta
lly
rele
van
tpr
imar
ym
ovem
ents
and
post
ura
lcon
trol
,dev
elop
men
tall
yap
prop
riat
eem
erge
nce
offl
exio
nan
dex
ten
sion
patt
ern
s,an
dde
velo
pmen
talp
rogr
essi
on.
●In
fan
tse
nso
ryan
dpe
rcep
tual
deve
lopm
ent.
●In
fan
tbe
hav
iora
lrep
erto
ire
(ph
ysio
logi
cal,
mot
or,s
tate
,an
din
tera
ctio
n).
●O
ralm
otor
deve
lopm
ent,
feed
ing
patt
ern
s(r
eadi
nes
scu
es,s
uck
/sw
allo
w/
resp
irat
ory
coor
din
atio
n,p
acin
g),f
eedi
ng
posi
tion
san
deq
uip
men
t,br
east
-fee
din
g,an
dla
ctat
ion
.●
Des
crip
tion
,adm
inis
trat
ion
,an
dps
ych
omet
ric
char
acte
rist
ics
ofa
min
imu
mof
fou
rin
fan
tin
stru
men
ts:
-E
arly
Fee
din
gSk
ill(
EF
S)A
sses
smen
t.3
-H
amm
ersm
ith
Neo
nat
alN
euro
logi
calE
xam
inat
ion
(Du
bow
itz)
.4
-F
inn
egan
Neo
nat
alA
bsti
nen
ceSc
ale.
5
-G
ener
alM
ovem
ent
Ass
essm
ent
(Pre
chtl
).6
-N
eon
atal
Beh
avio
ralA
sses
smen
tSc
ale
(NB
AS)
.7
-N
eon
atal
Infa
nt
Pai
nSc
ale
(NIP
S).8
-N
eon
atal
Ora
l-M
otor
Ass
essm
ent
Scal
e(N
OM
AS)
.9
-N
ewbo
rnB
ehav
iora
lObs
erva
tion
(NB
O).
10
-N
ewbo
rnIn
divi
dual
ized
Car
ean
dA
sses
smen
tP
rogr
am(N
IDC
AP
).11
-N
ICU
Net
wor
kN
euro
beh
avio
ralS
cale
(NN
NS)
.12
-N
urs
ing
Ch
ild
Ass
essm
ent
Fee
din
g(N
CA
F)
Scal
e.13
-P
rem
atu
reIn
fan
tP
ain
Pro
file
(PIP
P).
14
-T
est
ofIn
fan
tM
otor
Per
form
ance
(TIM
P).
15
-T
est
ofIn
fan
tM
otor
Per
form
ance
Scre
enin
gIn
ven
tory
(TIM
PSI
).16
●N
eon
atal
stru
ctu
rala
nd
fun
ctio
nal
impa
irm
ents
,act
ivit
yli
mit
atio
ns,
and
part
icip
atio
nre
stri
ctio
ns
invo
lvin
gpo
stu
rean
dm
ovem
ent.
Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 299
TABL
E3
Pla
nn
ing
and
Impl
emen
tin
gN
eon
atal
Inte
rven
tion
Rol
esC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Des
ign
,im
plem
ent,
and
eval
uat
ein
terv
enti
onpl
ans
and
stra
tegi
esin
coll
abor
atio
nw
ith
the
fam
ily
and
neo
nat
alte
am.
●C
olla
bora
tew
ith
the
infa
nt’s
med
ical
team
and
fam
ily
toid
enti
fym
easu
rabl
elo
ng-
term
and
shor
t-te
rmin
terv
enti
ongo
als
toop
tim
ize
fun
ctio
nal
outc
omes
and
min
imiz
eri
sk.
●D
eter
min
efr
equ
ency
,in
ten
sity
,an
dm
eth
ods
(e.g
.dir
ect,
con
sult
ativ
e)fo
rim
plem
enti
ng
ade
velo
pmen
tall
yap
prop
riat
eph
ysic
alth
erap
yin
terv
enti
onpl
an.
●A
pply
appr
opri
ate
han
dpl
acem
ent,
supp
ort,
and
adju
stm
ents
duri
ng
han
dlin
gof
neo
nat
es.
●Im
plem
ent
ther
apeu
tic
stra
tegi
esap
prop
riat
eto
gest
atio
nal
age
and
mat
ched
toth
ein
fan
t’sph
ysio
logi
cal,
mot
or,a
nd
stat
ere
gula
tion
stre
ngt
hs
and
vuln
erab
ilit
ies
and
neu
rode
velo
pmen
talr
isk.
Th
ese
stra
tegi
esm
ayin
clu
depo
siti
onin
g,sk
in-t
o-sk
inh
oldi
ng
(kan
garo
oca
re),
han
dlin
g,h
ydro
ther
apy
(sw
addl
edim
mer
sion
),sp
lin
tin
g,ta
pin
g,or
al-m
otor
/fee
din
g,se
lect
ive
ran
geof
mot
ion
(in
fan
tsw
ith
con
gen
ital
join
tm
obil
ity
rest
rict
ion
),so
ftti
ssu
em
obil
izat
ion
(su
rgic
alsc
arre
leas
e),a
nd
adap
tive
equ
ipm
ent
use
.●
Col
labo
rate
wit
hn
eon
atal
nu
rses
,nu
rse
man
ager
,an
dde
velo
pmen
talc
are
com
mit
tee
toim
plem
ent
mod
ific
atio
nof
the
phys
ical
,sen
sory
,an
dso
cial
envi
ron
men
tin
the
NIC
U(e
g,24
-hr
rest
/act
ivit
ype
rspe
ctiv
e;da
y-n
igh
tcy
clin
g;fe
edin
gon
dem
and;
non
han
dlin
gqu
iet
peri
ods)
.●
Col
lect
data
,mon
itor
prog
ress
,eva
luat
eef
fect
iven
ess,
and
mod
ify
ther
apeu
tic
stra
tegi
es,
plan
,an
dgo
als
acco
rdin
gly
toac
com
mod
ate
chan
ges
inth
ein
fan
t’sn
euro
deve
lopm
ent.
●D
emon
stra
tesu
cces
sfu
lstr
ateg
ies
topr
omot
efa
mil
y-in
fan
tin
tera
ctio
nan
dat
tach
men
t.●
Act
asa
reso
urc
eto
nu
rsin
gst
aff
mem
bers
and
fam
ilie
sfo
ru
nit
-wid
eim
plem
enta
tion
ofev
iden
ce-b
ased
,dev
elop
men
tall
yap
prop
riat
epr
acti
ces
and
ther
apeu
tic
stra
tegi
esin
toda
ily
care
givi
ng.
●U
sepa
ren
tco
nce
rns
and
prio
riti
esto
guid
eth
ede
sign
and
impl
emen
tati
onof
inte
rven
tion
.
●St
rate
gies
for
faci
lita
tion
ofm
ovem
ent
and
post
ure
inin
fan
tsbo
rnpr
emat
ure
lyor
wit
hm
edic
alco
mpl
icat
ion
s.●
Evi
den
ceba
sefo
rpo
siti
ons
topr
even
tor
redu
cede
form
itie
san
dto
incr
ease
fun
ctio
nin
infa
nts
.●
Infa
nt
resp
irat
ory
con
trol
and
feed
ing
para
met
ers
(eg,
coor
din
atio
nof
suck
,sw
allo
w,a
nd
brea
thin
g,fe
edin
gre
adin
ess
cues
).●
Ran
geof
bott
lean
dn
ippl
esi
zes,
nip
ple
flow
rate
s,an
dsp
ecia
lize
dfe
edin
gde
vice
s(H
aber
man
Fee
din
gSy
stem
;cle
ftpa
late
adap
tati
ons,
and
brea
st-
feed
ing
aids
).●
Infa
nt
self
-reg
ula
tion
beh
avio
rs.
●F
amil
y-ce
nte
red
care
mod
els
and
the
effe
ctof
fam
ily-
cen
tere
dca
repr
acti
ces
onfa
mil
you
tcom
es.
●C
ult
ura
l(fa
mil
y/pa
ren
ts;n
urs
ing)
diff
eren
ces
inca
regi
vin
gan
def
fect
son
fam
ily-
infa
nt
inte
ract
ion
,fam
ily
wel
l-be
ing,
and
infa
nt
deve
lopm
ent.
●G
rief
and
bere
avem
ent
proc
esse
s.
Dev
elop
and
impl
emen
tdi
sch
arge
plan
sin
coll
abor
atio
nw
ith
care
give
rsan
dco
mm
un
ity
reso
urc
ere
pres
enta
tive
s.
●F
orm
ula
tetr
ansi
tion
plan
sfo
rdi
sch
argi
ng
infa
nts
toth
eir
hom
esan
dco
mm
un
itie
s,sh
ort-
term
reh
abil
itat
ion
faci
liti
es,o
rsu
rgic
alce
nte
rs.
●C
reat
eli
nka
ges
toco
mm
un
ity
reso
urc
es,e
arly
inte
rven
tion
prog
ram
san
dN
ICU
foll
ow-u
pcl
inic
s.●
Edu
cate
pare
nts
,neo
nat
alca
regi
vers
,an
dco
mm
un
ity
reso
urc
ere
pres
enta
tive
son
:-
Pot
enti
alin
juri
esfr
omin
fan
tto
ys,s
eati
ng
devi
ces,
“ju
mpe
rs,”
and
wal
kers
inh
ome
envi
ron
men
ts;
-R
isk
ofto
rtic
olli
san
dpl
agio
ceph
aly
from
prol
onge
das
ymm
etri
calh
ead
posi
tion
duri
ng
slee
pan
daw
ake
peri
ods;
-Su
pin
esl
eepi
ng
acco
rdin
gto
the
reco
mm
enda
tion
sfr
omth
eA
mer
ican
Aca
dem
yof
Ped
iatr
ics;
-P
rovi
sion
ofop
port
un
itie
sfo
rsu
perv
ised
play
tim
ein
pron
epo
siti
ondu
rin
gaw
ake
peri
ods;
-P
osit
ion
ing
and
han
dlin
gto
mod
ify
atyp
ical
post
ure
san
dm
ovem
ents
ifpr
esen
tin
neo
nat
es.
●M
onit
orph
ysio
logi
cala
nd
beh
avio
ralt
oler
ance
duri
ng
pred
isch
arge
car
seat
tria
lsan
dre
com
men
dan
dfi
tal
tern
ate
equ
ipm
ent
asn
eede
d(c
arbe
d).
●G
rou
pdy
nam
icpr
oces
ses.
●In
fan
tan
dca
regi
ver
nee
dsin
the
hom
een
viro
nm
ent
incl
udi
ng
envi
ron
men
tal
mod
ific
atio
ns
tosu
ppor
tin
fan
tbe
hav
iora
lreg
ula
tion
.●
Mec
han
ism
sof
acqu
irin
gpo
siti
onal
plag
ioce
phal
yan
dse
con
dary
tort
icol
lis
and
exam
inat
ion
and
inte
rven
tion
opti
ons
for
man
agin
gth
eco
ndi
tion
s.●
Ear
lyin
terv
enti
onan
dco
mm
un
ity
reso
urc
es(e
g,pa
ren
tsu
ppor
tgr
oups
,th
erap
euti
can
dre
crea
tion
alpr
ogra
ms,
inte
rdis
cipl
inar
yN
ICU
foll
ow-u
ppr
ogra
ms)
.●
Fed
eral
man
date
s,st
ate
elig
ibil
ity
poli
cy,e
thic
alst
anda
rds,
and
loca
lgu
idel
ines
for
earl
yin
terv
enti
onse
rvic
es.
●P
ract
ice
guid
elin
esof
the
AP
TA
Sect
ion
onP
edia
tric
sfo
rph
ysic
alth
erap
ists
wor
kin
gin
earl
yin
terv
enti
on.
●O
utc
ome
mea
sure
sto
eval
uat
eim
pair
men
ts,a
ctiv
ity
lim
itat
ion
s,pa
rtic
ipat
ion
rest
rict
ion
,an
dfa
mil
ysa
tisf
acti
on.
●C
arse
atsa
fety
requ
irem
ents
and
post
ura
lsu
ppor
tst
rate
gies
for
infa
nts
born
pret
erm
and
atte
rm.
●Sa
fety
con
side
rati
ons
inth
eu
seof
infa
nt
toys
and
jum
pers
,an
din
jury
con
sequ
ence
sfr
omin
fan
tw
alke
rsin
hom
een
viro
nm
ents
.●
Pat
tern
sof
mu
scu
losk
elet
alm
alal
ign
men
tan
dat
ypic
alm
ovem
ent
asso
ciat
edw
ith
prol
onge
du
seof
NIC
Ueq
uip
men
t(r
espi
rato
ry,i
nfu
sion
,ref
lux
wed
ges)
.
NIC
Uin
dica
tes
neo
nat
alin
ten
sive
care
un
it;A
PT
Are
fers
toA
mer
ican
Ph
ysic
alT
her
apy
Ass
ocia
tion
.
300 Sweeney et al Pediatric Physical Therapy
physical therapy competencies were updated through aconsensus process by a 3-member NICU Task Force ofpediatric PTs with extensive neonatal expertise and geo-graphical diversity, appointed by the Section on Pediat-rics of the APTA. External review of the clinical compe-tencies and algorithm was conducted by an additionalexpert panel of 5 pediatric PTs with neonatal expertiserepresenting varying geographical regions of the UnitedStates. Further validation of the neonatal physical ther-apy competencies through a nation-wide practice anal-ysis could provide an expanded framework for neonatol-ogy fellowship programs and for delineation of thepractice.
CLINICAL DECISION-MAKING ALGORITHM
An algorithm for clinical decision making in neonatalphysical therapy, revised from the 1999 algorithm,2 reflectsthe needs of contemporary practice and is outlined in Fig-ures 1 to 3. Pathways for neonatal physical therapy man-agement decisions are described for examination, evalua-tion, intervention, and re-examination with terminologycompatible to the Guide to Physical Therapist Practice.17
The algorithm was modeled from the Hypothesis-OrientedAlgorithm for Clinicians I18 and II.19 The framework of theIFC20 adopted by the House of Delegates, APTA, 200821
and the Synactive Theory of Development proposed byAls22 are embedded in this algorithm. The algorithm alsoprovides a means for using evidence in decision making.
During the history taking process (Fig. 1), the primarycare team and family identify strengths and challenges(PFSL) and decide on an examination strategy. On thebasis of the observation of the infant’s activities, an infantstrengths and challenges list is generated. The neonatal PTexamines strengths and challenges (ISCL) at the bodyfunction and structure, activity, and participation levels ofthe ICF, which leads to the therapist’s strengths andchallenges list (TSCL). All 3 strengths and challengeslists are merged and appropriate infant-centered/family-centered goals are then developed.
Before intervention (Fig. 2), the neonatal PT develops anintervention plan based on infant-centered/family-centeredgoals and implements this plan with respect to the car-diovascular/pulmonary and integumentary systems17
(autonomic system),22 the musculoskeletal and neuro-muscular systems17(motor behavior),22 behavioral state,22
and responsivity10 (attentional-interactive behaviors).22
The 4 categories are arranged according to (1) coordina-tion, communication, and documentation such as support-ing, developing, and promoting family/professional rela-tionships; (2) education and consultation for family andprimary care team such as training to support and promotethe infant’s care, development/learning, health, nutrition,and safety; and (3) interventions provided by the PT, fam-ily, and members of the primary care team such as (a) use ofadjunct accessories/or aids that support the infant in self-regulation of physiological state, promotion of smooth coor-dinated movement, and organization of movement includinghand to mouth behavior for self-regulation of behavioral state
TABL
E4
Con
sult
atio
n
Rol
eC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Con
sult
and
coll
abor
ate
wit
hh
ealt
hpr
ofes
sion
als,
fam
ilie
s,pr
ofes
sion
alan
dco
mm
un
ity
orga
niz
atio
ns
orag
enci
es,a
nd
inte
rest
edm
embe
rsof
the
gen
eral
publ
ic.
●A
sses
sn
eeds
and
expe
cted
outc
omes
ofco
nsu
ltat
ion
.●
For
mu
late
goal
s,cr
iter
ia,a
nd
tim
elin
esan
dse
lect
con
sult
atio
nm
odel
sin
coll
abor
atio
nw
ith
clie
nts
.●
Iden
tify
inte
rnal
and
exte
rnal
proc
edu
rala
nd
regu
lato
rygu
idel
ines
asw
ella
ske
yst
akeh
olde
rs(m
anag
emen
tan
dfi
duci
ary)
.●
Col
labo
rate
inid
enti
fyin
gan
dan
alyz
ing
prob
lem
san
din
deve
lopi
ng
ben
chm
ark
obje
ctiv
esan
dac
tion
plan
sto
ach
ieve
outc
omes
.●
An
alyz
ean
din
terp
ret
chan
gepr
oces
s(i
ndi
vidu
alst
yles
and
rate
sof
chan
ge).
●E
valu
ate
outc
ome
and
reco
mm
end
revi
sion
ofac
tion
plan
s.●
Iden
tify
oppo
rtu
nit
ies
for
pote
nti
alre
ferr
als,
coll
abor
atio
n,a
nd
reso
urc
esh
arin
gam
ong
oth
erdi
scip
lin
esor
serv
ices
.
●N
eeds
asse
ssm
ent
proc
esse
s.●
Con
sult
atio
nm
odel
s.●
Cli
nic
alre
ason
ing
proc
esse
s.●
Org
aniz
atio
nal
chan
gepr
oces
ses:
cata
lysi
san
dpa
tter
ns
ofin
nov
atio
nan
dch
ange
.●
Com
mu
nic
atio
nan
dle
ader
ship
styl
es.
●C
omm
un
ity
and
mu
ltid
isci
plin
ary
reso
urc
es.
Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 301
TABL
E5
Scie
nti
fic
Inqu
iry
Rol
esC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Inco
rpor
ate
evid
ence
-ba
sed
lite
ratu
rein
ton
eon
atal
prac
tice
.
●R
evie
wan
dcr
itic
ally
anal
yze
neo
nat
alm
edic
ine,
neo
nat
aln
urs
ing,
pedi
atri
cph
ysic
alth
erap
y,ps
ych
olog
y,an
dn
eon
atal
resp
irat
ory
ther
apy
lite
ratu
re.
●Id
enti
fym
ech
anis
ms
toef
fect
ivel
ydi
ssem
inat
ese
lect
ed,c
urr
ent
rese
arch
rela
ted
ton
eon
atal
phys
ical
ther
apy
toN
ICU
staf
fm
embe
rsan
dfa
mil
ies.
●A
pply
rese
arch
and
evid
ence
-bas
edpr
acti
celi
tera
ture
into
care
givi
ng
plan
san
din
terv
enti
ons.
●L
iter
atu
rese
arch
ing
proc
edu
res.
●St
eps
for
crit
iqu
ing
med
ical
lite
ratu
re.
●L
evel
sof
evid
ence
from
evid
ence
-bas
edm
edic
ine
fram
ewor
k(C
och
ran
ew
ebsi
te,
Oxf
ord
Cen
ter
for
Evi
den
ce-B
ased
Med
icin
eh
ttp:
//w
ww
.ceb
m.n
et/
●A
dmin
istr
ativ
em
ech
anis
ms
for
mod
ifyi
ng
clin
ical
proc
edu
res
orpr
otoc
ols
onth
eba
sis
ofn
ewre
sear
chev
iden
ce.
Supp
ort
orpa
rtic
ipat
ein
rese
arch
invo
lvin
gin
fan
ts,p
aren
ts,o
rca
regi
vers
inn
eon
atal
care
un
its.
●C
reat
ere
sear
chqu
esti
ons
onn
eon
atal
topi
csfo
rcl
inic
alre
sear
cher
s.●
Rev
iew
the
lite
ratu
reto
iden
tify
rela
ted
stu
dies
,est
abli
sha
basi
sfo
rth
ere
sear
chqu
esti
ons
and
pote
nti
alm
easu
rem
ent
met
hod
s,an
dev
alu
ate
desi
gns
and
stat
isti
calm
eth
ods
use
din
sim
ilar
stu
dies
.●
For
mu
late
test
able
hyp
oth
eses
.●
Est
abli
shan
dde
fin
ein
depe
nde
nt
and
depe
nde
nt
vari
able
s.●
Det
erm
ine
the
rese
arch
desi
gnan
dm
eth
ods
best
suit
edto
answ
erth
ere
sear
chqu
esti
on.
●E
stab
lish
reli
abil
ity
inth
eu
seof
the
inst
rum
ents
chos
enfo
rda
taco
llec
tion
.●
An
alyz
ean
din
terp
ret
data
.●
Est
abli
shco
ncl
usi
ons
and
clin
ical
impl
icat
ion
sfr
omth
eda
ta.
●Id
enti
fyli
mit
atio
ns
ofth
est
udy
and
sugg
esti
ons
for
futu
rere
sear
ch.
●D
isse
min
ate
resu
lts
ofth
ere
sear
ch.
●E
vide
nce
-bas
edpr
acti
ceco
nce
pts
(pri
nci
ples
and
evid
ence
hie
rarc
hy)
.●
Res
earc
hde
sign
and
mea
sure
men
tm
eth
ods.
●C
omm
onst
atis
tica
ltes
tsu
sed
inn
eon
atal
and
pedi
atri
cph
ysic
alth
erap
yre
sear
ch.
●R
esou
rces
for
con
sult
atio
nin
desi
gn,s
tati
stic
alan
alys
is,a
nd
fun
din
g.●
Eth
ical
prin
cipl
esgo
vern
ing
rese
arch
and
prot
ecti
ng
infa
nt
part
icip
ants
.●
Inst
itu
tion
alR
evie
wB
oard
proc
edu
res
for
clin
ical
rese
arch
prop
osal
appr
oval
and
mon
itor
ing.
●R
esea
rch
repo
rtin
gm
ech
anis
ms
for
pres
enta
tion
san
dpu
blic
atio
ns.
NIC
Uin
dica
tes
neo
nat
alin
ten
sive
care
un
it.
TABL
E6
Cli
nic
alE
duca
tion
and
Self
-Lea
rnin
g/P
rofe
ssio
nal
Dev
elop
men
t
Rol
esC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Com
mu
nic
ate,
dem
onst
rate
,an
dev
alu
ate
neo
nat
alph
ysic
alth
erap
yca
repr
oces
ses
wit
hN
ICU
prof
essi
onal
san
dot
her
care
give
rs.
●Id
enti
fyle
arn
erkn
owle
dge
and
skil
lnee
dsan
dpr
epar
ecl
inic
altr
ain
ing
that
refl
ects
base
lin
ean
dex
pect
edac
hie
vem
ent
leve
ls.
●E
stab
lish
trai
nin
gob
ject
ives
,pri
orit
ies,
and
tim
elin
e.●
Ch
oose
teac
hin
gm
eth
ods
and
form
at.
●C
omm
un
icat
ein
form
atio
n,d
emon
stra
tepr
oced
ure
s,ar
ran
gepr
acti
cese
ssio
ns
and
repe
atde
mon
stra
tion
s,an
dpr
ovid
efe
edba
ckw
ith
lear
ner
son
perf
orm
ance
.●
Eva
luat
ele
arn
erpe
rfor
man
cean
dte
ach
ing
effe
ctiv
enes
s.
●Sc
ien
tifi
can
dth
eore
tica
lbas
esan
dpr
oced
ure
sin
phys
ical
ther
apy
for
neo
nat
es.
●A
dult
lear
nin
gst
yles
and
stag
esof
lear
nin
g.●
Edu
cati
onal
proc
esse
sto
incl
ude
obje
ctiv
es,m
eth
ods,
sequ
enci
ng,
and
eval
uat
ion
.
Pu
rsu
eon
goin
gco
nti
nu
ing
edu
cati
onin
prac
tice
topi
csre
late
dto
neo
nat
olog
y.
●Se
lf-a
sses
scl
inic
alco
mpe
ten
cies
and
know
ledg
eli
mit
atio
ns
inph
ysic
alth
erap
yfo
rn
eon
ates
.●
Eva
luat
ean
dse
lect
con
tin
uin
ged
uca
tion
opti
ons
toad
dres
ssk
illa
nd
know
ledg
ede
fici
tar
eas.
●Se
lf-r
efle
ctio
npr
oces
s.●
Res
ourc
esfo
rse
min
ars
onn
eon
atal
care
topi
cs,N
ICU
clin
ical
trai
nin
gop
port
un
itie
s,an
dpo
ten
tial
men
tors
wit
hex
pert
ise
inn
eon
atol
ogy.
NIC
Uin
dica
tes
neo
nat
alin
ten
sive
care
un
it.
302 Sweeney et al Pediatric Physical Therapy
TABL
E7
Adm
inis
trat
ion
Rol
esC
lin
ical
Pro
fici
enci
esK
now
ledg
eA
reas
Pla
nan
dad
min
iste
ra
neo
nat
alph
ysic
alth
erap
ypr
ogra
m
●D
evel
opa
mis
sion
and
phil
osop
hy
for
the
neo
nat
alph
ysic
alth
erap
ypr
ogra
mth
atis
con
sist
ent
wit
hth
em
issi
ons
and
phil
osop
hy
ofth
eh
ospi
tala
nd
new
born
med
icin
ese
rvic
e.●
Ass
ess
the
serv
ice
nee
dsof
the
targ
etn
eon
atal
popu
lati
onan
des
tabl
ish
crit
eria
for
neo
nat
alph
ysic
alth
erap
yre
ferr
al.
●Se
lect
and
assi
gnpr
iori
ties
toth
eph
ysic
alth
erap
ypr
oced
ure
sfo
rn
eon
ates
that
wil
lbe
offe
red.
●Id
enti
fyan
dac
quir
eph
ysic
alth
erap
yre
sou
rces
for
serv
ing
neo
nat
es,i
ncl
udi
ng
PT
sw
ith
prec
epte
dtr
ain
ing,
supp
lies
,an
dti
me.
●E
stab
lish
fin
anci
alsu
ppor
tan
dde
velo
por
part
icip
ate
inde
velo
pin
ga
neo
nat
alph
ysic
alth
erap
yse
rvic
ebu
dget
base
don
curr
ent
staf
fre
sou
rces
and
fore
cast
edel
igib
len
eon
atal
popu
lati
on.
●D
evel
opan
dim
plem
ent
phys
ical
ther
apy
poli
cies
and
proc
edu
res
for
neo
nat
esin
clu
din
gre
ferr
alm
ech
anis
m,i
nte
nsi
ty(f
requ
ency
;du
rati
on),
supe
rvis
ion
and
prec
epti
ng
proc
esse
s,an
ddo
cum
enta
tion
form
atan
dti
mel
ines
.●
Iden
tify
eth
ical
and
lega
lsta
nda
rds
and
inco
rpor
ate
them
into
neo
nat
alph
ysic
alth
erap
ypr
acti
ce.
●P
rin
cipl
esan
dse
quen
ces
for
deve
lopi
ng
and
adm
inis
trat
ing
clin
ical
prog
ram
s.●
Res
ourc
em
anag
emen
tpr
inci
ples
for
anal
yzin
gpe
rson
nel
,cos
t,an
dti
me
requ
irem
ents
for
neo
nat
alph
ysic
alth
erap
yse
rvic
es.
●R
isk
man
agem
ent
prin
cipl
esan
dpr
oces
ses.
●L
eade
rsh
ippr
inci
ples
and
supe
rvis
ion
mod
els.
●M
anag
edca
repr
oces
ses
and
ifap
plic
able
,con
trac
tn
egot
iati
onst
rate
gies
.●
Cod
eof
eth
ics,
stan
dard
sof
prac
tice
,an
dpa
ram
eter
sof
lega
lpra
ctic
efr
omth
eA
PT
Aan
dst
ate
hea
lth
prof
essi
onli
cen
sebo
ards
.
Dev
elop
aph
ysic
alth
erap
yri
skm
anag
emen
tpr
ogra
m.
●D
ocu
men
tst
anda
rdop
erat
ing
proc
edu
res
for
man
agin
gph
ysio
logi
calr
isk
duri
ng
obse
rvat
ion
,in
fan
tex
amin
atio
ns,
and
phys
ical
ther
apy
serv
ices
inth
eN
ICU
.●
Dev
elop
clin
ical
prot
ocol
sfo
rh
igh
risk
oru
nu
sual
proc
edu
res
(eg,
extr
emit
yta
pin
g,so
ftti
ssu
em
obil
izat
ion
,neo
nat
alh
ydro
ther
apy)
.●
Est
abli
shpr
oced
ure
sfo
rm
anag
ing
inad
vert
ent
occu
rren
ces
ofad
vers
eev
ents
duri
ng
prov
isio
nof
phys
ical
ther
apy
serv
ices
inth
eN
ICU
.●
Del
inea
tepr
oced
ure
sfo
rad
vers
eev
ent
docu
men
tati
on,f
ollo
w-u
ppl
an,a
nd
clin
ical
teac
hin
gon
anal
yzin
gan
dpr
even
tin
gth
ead
vert
ent
occu
rren
ce.
●N
orm
alan
dpa
thol
ogic
alra
nge
sof
phys
iolo
gica
lval
ues
and
mu
scu
losk
elet
alpa
ram
eter
sfo
rin
fan
tsat
term
and
pret
erm
gest
atio
nal
ages
.●
En
viro
nm
enta
l(ph
ysic
alan
dso
cioc
ult
ura
l)ri
skfa
ctor
san
dth
eir
infl
uen
ceon
the
deve
lopm
ent
ofn
eon
ates
.●
Ris
km
anag
emen
tm
odel
san
dpr
inci
ples
.
Eva
luat
eth
eef
fect
iven
ess
ofa
neo
nat
alph
ysic
alth
erap
ypr
ogra
m.
●E
valu
ate
and
mon
itor
qual
ity
ofca
rean
did
enti
fyop
port
un
itie
sfo
rpr
acti
cech
ange
thro
ugh
revi
ews
ofca
ses
and
reco
rds
wit
hpe
ers.
●E
valu
ate
and
mon
itor
clin
ical
prod
uct
ivit
y.●
An
alyz
eef
fect
iven
ess
ofin
terv
enti
ons
onin
fan
tan
dfa
mil
yfu
nct
ion
ing
and
part
icip
ate
inon
goin
gqu
alit
yas
sura
nce
/im
prov
emen
tin
itia
tive
sin
the
NIC
U.
●D
eter
min
eev
iden
ceba
sefo
rex
amin
atio
ns
and
inte
rven
tion
sim
plem
ente
d.●
Con
duct
gen
eral
revi
ewof
phys
ical
ther
apy
prog
ram
wit
hn
eon
atal
med
ical
and
nu
rsin
gm
anag
ers.
●Q
ual
ity
asse
ssm
ent/
impr
ovem
ent
mod
els
and
met
hod
sfo
rap
plic
atio
nto
clin
ical
case
load
san
dpr
ogra
ms.
●P
rogr
amev
alu
atio
npr
inci
ples
and
met
hod
s.●
Evi
den
ce-b
ased
prac
tice
con
cept
san
dpr
inci
ples
.●
Cri
tica
lin
quir
yan
dev
iden
ce-b
ased
prac
tice
proc
esse
sto
eval
uat
en
eon
atal
and
fam
ily
inte
rven
tion
s.
AP
TA
indi
cate
sA
mer
ican
Ph
ysic
alT
her
apy
Ass
ocia
tion
;NIC
U,n
eon
atal
inte
nsi
veca
reu
nit
.
Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 303
and (b) physical and social environment modificationssuch as dimming lights and decreasing noise to supportphysiological, motor, or behavioral stability and to pro-mote infant/caregiver interaction during feeding in the
NICU. Interventions are also directly provided by the neo-natal PT. Direct physical therapy handling is a primaryservice provided by the neonatal PT to address impair-ments, activity limitations, and participation restrictions.
• Collect initial data [e.g. history (infant, maternal, family); chart review (systems review, medication, feeding, sleep/wake cycles/24 hours, medical problems); primary care team interview; family interview; environmental review (e.g. location, objects, light sound, activity level)]
• Generate primary care team and family identified strengths and challenges list (PFSCL)
• Formulate examination strategy• Conduct examination and evaluate data within the first week of admittance to
NICU if infant medically stable
• Ability of infant to demonstrate age appropriate organization and self-regulation during rest, caregiving, social interaction, and feeding:• Autonomic system: color, respiration patterns, visceral stability)• Motor system: posture, tone, movements including antigravity movements such as head in
midline, hands to midline, hands to mouth, reciprocal kicking; hand clasping, foot bracing• State system: behavioral states (sleep, wake and transition states), habituation and
responsivity or the ability to interact with the social and physical environment• Ability of infant to demonstrate age appropriate response to sensory information • Ability of caregivers (families and professionals) to interact with infant that best supports and
promotes optimal development of infant
Consultation if needed
Consultation if neededConsultation if needed
History
Observe Infant and Caregivers Functional and Participatory Performance
IdentifyStrengths andChallenges
PerformAdditional Diagnostic Procedures
Formulate Examination Strategy
Conduct Examination and Evaluate Data
For each existing challenge For each anticipated challengeGenerate hypotheses for why challenge exists Identify rationale why
anticipated challenge likely
No
No
YesNo
Reexamine in 10 days orsooner if needed
Environmental and Personal Supports and
Constraints on Body Functions and
Structures, Activities, and Participation
Activities and Participation and Activity
Limitations and Participation Restrictions
Body Functions and Structures and Impairments
Reexamine in 10 daysReexamine in 10 days
Yes
Generate infant strengths and challengeslist (ISCL)
Generate Therapist Strengthsand Challenges List (TSCL)
Merge and Refine Strengths andChallenges Lists (PFSCL, ISCL, TSCL)
Clinical Decision-Making Algorithm for Neonatal Physical Therapy
(CDMANPT) – PART 1Examination
For each challenge (existing or anticipated) establish one or more goals that can be reasonably achieved and that are functional and measurable with a time frame. Goals areinfant/family centered and represent outcomes that have value to infant and family.
Fig. 1. Clinical decision-making algorithm for neonatal physical therapy practice—Part 1: Examination.
304 Sweeney et al Pediatric Physical Therapy
No direct physical therapy handling indicates that neonatalPTs should not engage in providing primary services to theinfant.
The neonatal PT conducts re-examination (Fig. 3) todetermine (1) changes in the infant’s status, (2) whetherinitial infant-centered/family-centered goals and outcomeswere achieved, and (3) if not, to modify or redirect com-ponents of the intervention plan to achieve goals and out-comes. The clinical decision-making sequence as outlinedin the algorithm not only affords the neonatal PT pathways
for making evidence-based clinical decisions for the care ofinfants in the NICU but also provides the therapist with aframework to support clinical reasoning in neonatal phys-ical therapy.
CONCLUSIONS
To guide the specialized practice of neonatal physicaltherapy, clinical training models have been presented androles and proficiencies were outlined. A decision-makingalgorithm offers a flow chart for clinical reasoning. Before
CDMANPT – PART 1(Continued)Intervention
Perform Non- invasive Evidenced- BasedTherapeutic Intervention Plan and Strategies*
*Therapeutic intervention strategies not all inclusive†Accessories- adjunct aids to support care, i.e. finger and foot rolls, buntings, foam inserts, nests, pacifiers.‡ Direct physical therapy handling – primary service provided by therapist addressing specific impairments, activity limitations, or participation restrictions.
Cardiovascular/Pulmonary, Integumentary Systems
Coordination,communication,documentation
Education and consultation for family and primary care team
Interventions– Environmental alterations/ modifications(physical and social)– Supportive caregiving– Individualized positioning–Accessories† topromote self- regulation ofphysiologicalbehaviors– No direct physical therapy handling‡
Behavioral State
Coordination,communication,documentation
Education and consultation for family and primary care team
Interventions–Environmental
alterations/modifications(physical and social)
–Supportive caregiving–Individualized positioning
–Promote hand to mouth behavior for self- regulation of state
–Organization of sleep/wake cycles
–Direct PT handling•Hydrotherapy by PT•Gradedvestibular/kinesthetictherapeutics by PT or other caregivers
Responsivity
Coordination,communication,documentation
Education and consultation for family and primary care team
Interventions–Environmentalalterations/modifications(physical and social)
–Individualizedpositioning
–Direct PT handling•Individualized sensory input•Supportive holding-Visual tracking of
slowly moving face or toy in vertical, horizontal, and circular paths
-Auditory localization of quiet, soft voice orrattle to left and right
Musculoskeletal, Neuromuscular Systems
Coordination,communication,documentation
Education and consultation for family and primary care team
Interventions–Environmentalalterations/modifications(physical and social
– Planned handling during caregiving activities
– Individualized positioning– †Accessories to promote smoothcoordinatedmovements & self– regulation of movements
–Direct PT handling• Antigravity motoric
behaviors of head, neck, and extremities
•Assist coordination of sucking and swallowing; increase fluid intake
• Splints and taping• Hhydrotherapy by PT
Design, implement, and evaluate effectiveness of individualized, relationship-based, evidence-based family- centered developmental supportive care plan and strategies
Support, develop, and promote family/professional partnerships/relationships through: acknowledgement of personal values and beliefs; active participation, collaboration, respect, and education and training to support and promote infant’s care, development/learning, health, nutrition, and safety.
Fig. 2. Clinical decision-making algorithm for neonatal physical therapy practice—Part 1: Intervention.
Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 305
working in a neonatal unit, pediatric PTs must have pre-cepted clinical training to develop refined skills in exam-ining and intervening with fragile, vulnerable infants withstructural, physiological, and behavioral vulnerabilitiespredisposing them to become unstable during routine pro-cedures. Because each contact by the PT involves ongoingexamination, interpretation, and modification or rese-quencing of procedures, the NICU is not an appropriatesetting for PT assistants and aides and PT generalists andstudents. The potential to do harm with this vulnerableinfant population must be recognized. A caring approachand good intentions do not substitute for focused, precepted
clinical training in the range of competencies outlined forinfant-centered and family-centered care. Instead, interestedpractitioners will benefit from structured, mentored compe-tency-based training in neonatal physical therapy.
These guidelines may be used as a framework for de-veloping competency training mechanisms for PTs enter-ing neonatal practice, practitioners seeking more advancedlevels of neonatal care competencies, and directors of pe-diatric residency and neonatology fellowship programs.In part II of the practice guidelines, theoretical frame-works and evidence-based practice recommendationswill be delineated.
Goals Achieved• Document goal attainment and
elimination of challenges– Infant will be at appropriate
developmental level for corrected gestational age
– Infant will demonstrate successful self- regulation during social interaction and family and caregiving routines
– Infant will take all feeds through nipple demonstrating age appropriate suck- swallow-breathe coordination with feedings lasting <30 minutes each
– Infant will demonstrate organized sleep/wake cycles
• Discharge to home when all goals and challenges are met and family ready to care for and nurture their infant at home
• Implement infant and family transition from hospital to community resources
NoYes
For existing challenges For anticipated challenges
Have goals been met? Have anticipated challenges occurred?
Are strategies being implemented correctly?
Go to box marked Goal(s) Achieved
Is therapeutic intervention plan correct?
ImproveImplementation (go to Part 1; Interventiomn)
Are strategies appropriate?
Change strategies (go to Part 1 Intervention)
Change plan(go to Part 1: Intervention)
Re-evaluate viability of goals
Viable goals Non-viable goals
Continue implementation of plan and strategies (go to Part 1: Intervention)Plan reexamination
Generate new goals after consultation with primary care team and family (go to establishment of goals, Part 1: Examination)Document need and nature of modification
Add challenge to existing challenge list. Does new challenge create new anticipated challenges? Add to anticipated challenge list
Eliminate anticipated challenges from list
Yes No
Yes No
Yes No
Yes No
CDMANPT – PART 2Reexamination
Reexamination of Challenges
Fig. 3. Clinical decision-making algorithm for neonatal physical therapy practice—Part 2: Re-examination.
306 Sweeney et al Pediatric Physical Therapy
ACKNOWLEDGMENTS
The authors express appreciation to the medical illustra-tor, Thomas Pierce, BA, for graphic expertise and to the fol-lowing physical therapists serving as content reviewers: MarieReilly, PT, PhD; Jan McElroy, PT, DPT, MS, PCS; Beth Mc-Manus, PT, ScD, MPH; Elizabeth Ennis, PT, EdD, PCS, ATP;and Sheree Chapman York, PT, MS, PCS.
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Pediatric Physical Therapy Neonatal PT Practice Guidelines and Training Models 307
